Friday, August 21, 2015

Unusual sensory processing
experiences are common among individuals with autism spectrum disorder (ASD),
and are now part of the Diagnostic and Statistical Manual 5th Edition (DSM-5)
diagnostic criteria. Although previous research indicates that ASD traits are
associated with sensory scores in the general population, it is unclear whether
they characterize the “broader phenotype” of ASD which includes individuals with
mild impairments in social and communication skills that are similar to those
shown by individuals with ASD, but exhibited to a lesser degree. A study published in the Journal of
Autism and Developmental Disorders sought to replicate the reported
relationship between ASD traits and sensory traits across the entire range of symptom
severity, and to investigate its specificity in a large sample of adults both
with and without ASD. Adults (n = 772) with and without an ASD were administered
the Autism Spectrum Quotient (AQ) together with the Adult/Adolescent Sensory
Profile (AASP), the Cardiff Anomalous Perceptions Scale (CAPS), and the Glasgow
Sensory Questionnaire (GSQ), all questionnaire measures of abnormal sensory
responsivity. Of the 772 participants, 23 reported having autism and 55
reported a first-degree relative with the disorder. Another 147 participants
indicated having another psychiatric condition, such as depression, and 85
reported having migraine headaches on a regular basis.

The results indicated that
self-reported abnormal sensory experiences were positively correlated with ASD
trait scores on all three sensory questionnaires. The more autistic traits,
the more sensory problems he or she reported. Individuals with the
most autism traits, such as narrow interests or social difficulties, showed
high levels of atypical sensory behavior on all three questionnaires. Although
the study’s sample was predominantly (72 %) female, the investigators
found that the relationship between sensory symptoms and ASD traits was very
similar for both genders. They also found that ASD traits were correlated with
levels of anxiety symptoms. Participants who reported being anxious had both
more autism traits and more unusual sensory responses than those who were not
anxious. This suggests that abnormalities with sensory processing and anxiety
symptoms are related, yet separate, phenomena.

These results have
implications for the integration of sensory processing abnormalities into the
diagnosis and assessment of ASD. For example, the study confirms the association
between sensory experiences and autism across the entire autism spectrum,
suggesting that sensory traits might serve as a dimensional measure of the
severity of ASD. It should be noted, however, that unusual sensory experiences
are not unique to ASD. The researchers found that trait anxiety, a history of
psychiatric conditions, and a history of migraines were all associated with
higher sensory scores, even after controlling for ASD traits. Thus, individuals
with these conditions may report high levels of unusual sensory experiences,
which could potentially lead to a misdiagnosis of ASD. It also appears unlikely
that abnormal sensory experiences underpin all ASD symptoms. Even so, it does appear that if sensory symptoms were treated successfully, then some
core ASD symptoms, such as stereotypies, might also be reduced (or vice versa).
Further research is needed to examine this issue. Finally, the cognitive/biological
basis of the relationship between autistic traits and sensory problems is
unknown, and further work is required to determine whether improving sensory
processing could effectively reduce the severity of ASD symptoms.

Wednesday, August 19, 2015

Young
adults with autism are facing significant challenges as they transition to
adulthood, a national report suggests, with
many on the spectrum finding themselves unemployed, isolated, and lacking
services. The "National Autism Indicators Report: Transition into Young
Adulthood" from Drexel University’s A.J. Drexel Autism Institute
is a comprehensive report (available free online) that presents new findings
about a wide range of experiences and outcomes of youth on the autism spectrum
between high school and their early 20s. The report is a collection of
indicators that focuses national attention on outcomes which are almost
universally lower for those on the autism spectrum compared to their peers with
other types of disabilities and serves as a call to action to fill the
remaining large gaps in knowledge. Key findings include:

Over one-third (37 percent) of young adults were disconnected during their early 20s, meaning they never got a
job or continued education after high school. In comparison, less than
eight percent of young adults with other types of disabilities were
disconnected.

Approximately 26 percent of young adults and
28 percent of those unemployed and not in school received no services
which could help them with employment, continue their education, or live
more independently.

Just 58 percent of young adults worked for pay
outside the home between high school and their early 20s, a rate far lower
than young adults with other types of disabilities. Those with jobs
generally worked part-time for relatively low wages.

Approximately one in four young adults were
socially isolated, meaning they never saw or talked with friends and were
never invited to social activities within the past year.

Only about one in five ended up living
independently (without parental supervision) in the period between high
school and their early 20s.

Sixty percent of youth had at least two health
or mental health conditions in addition to autism spectrum disorder. Over
half of youth had co-occurring ADD/ADHD and anxiety issues in adolescence.
Three-quarters of youth took at least one kind of medication on a regular
basis for any health or mental health issue.

Nearly 50% of youth experienced threats and
bullying during high school. Over one-quarter (27 percent) of adolescents
engaged in some type of wandering behavior in which they impulsively left
a supervised situation, increasing their risk of becoming lost and going
missing.

Transition Planning, a key process for helping
youth build skills and access services as they enter adulthood, was
frequently delayed. Just 58 percent of youth had a transition plan by the
federally required age.

The creation of effective
and affordable programming tailored to meet the needs of the 50,000 individuals
with autism who leave high school each year - each with unique strengths,
interests, and challenges - is an urgent task facing our society. It is clear
that we are not succeeding as a nation in helping autistic adults to thrive to
the best of their abilities and attain a high quality of life. It is time for
new approaches.

“This is the most
comprehensive report to date describing what we know about young adults with
autism as a whole and across the various parts of their lives. Yet, it
represents only a fraction of what we need to know. Huge gaps remain,” said
Anne M. Roux, MPH, research scientist at the A.J. Drexel Autism Institute in
the Life Course Outcomes Research Program and lead author of the report.
Although these indicators don’t tell us why outcomes are worse for those with
autism compared to youth with other disabilities, this report is an important
first step toward addressing the gaps in what we know, as we work to build an
evidence base about how to help achieve better outcomes.

Tuesday, August 11, 2015

Music therapy has become
an integral part of many programs for children with autism. The broad category
of music therapy is generally described as interventions that seek to teach
individual skills or goals through music. Music therapists use their training
as musicians, clinicians, and researchers to effect changes in cognitive,
physical, communication, social, and emotional skills. According to the National Autistic Society, “Music therapy
aims to encourage increased self-awareness/self-other awareness, leading to
more overt social interactions. The therapy stimulates and develops the
communicative use of voice and pre-verbal dialogue with another, establishing
meaning and relationship to underpin language development. The client may also
benefit from increased tolerance of sound, tolerance of and capacity for
two-way communication.”

Research
Autism reports strong positive evidence from peer-reviewed journals that
support the effectiveness of music therapy for individuals with autism spectrum
disorders (ASD). Based on the literature to date, music therapy has shown good
effects in influencing joint attention, social interaction, verbal and gestural
communication and behavior. It is considered to be a useful intervention,
particularly with young children, and where language acquisition is either
delayed or disordered to a severe degree. Currently, music therapy
is identified as an emerging intervention by the National Autism Center (2015)
and incorporates many of the identified ASD-specific evidence-based practices.Supporters of music therapy emphasize
that it can be used to develop social engagement, joint attention, communication
abilities, while also addressing emotional needs and quality of life.

A study published in the
journal Autism
provides further support for the effectiveness of music therapy with ASD. This
study investigated the social-motivational aspects of musical interaction
between the child and the therapist in improvisational music therapy by
measuring emotional, motivational and interpersonal responsiveness in children
with autism during joint engagement episodes. Improvisational music therapy is
an individualized intervention that facilitates moment-by-moment motivational
and interpersonal responses in children with autism. Compared with other
therapeutic interventions utilizing music as a background or contingent
stimulus, improvisational music therapy involves the interactive use of live
music for engaging clients to meet their therapeutic needs. It is gaining
growing recognition as an effective intervention addressing fundamental levels
of spontaneous self-expression, emotional communication and social engagement
for individuals with a wide range of developmental disorders.

Design

This randomized controlled
exploratory study employed a single subject comparison design in two different
conditions (improvisational music therapy versus toy play sessions) and two different
parts of a session (an undirected/child-led part versus a more directed/therapist-led
part) in each condition. The objective was to compare the effects of these two
different media (music versus toys) and to determine how children respond in a musical
context with or without direction, compared with a non-musical context such as
play activities with toys with or without direction.

Participants and Procedure

Participants were children
aged between 3 and 5 who were not previously treated with either music therapy
or play therapy. A total of ten children (all male) completed the clinical
trials. Five children were non-verbal while the other five were verbal with
varying degrees of language skills. Eight children were in preschool special
education, and two were in mainstream preschool programs that included
additional therapeutic supports, such as speech language therapy. The children
were randomly assigned either to have the music therapy sessions first and the
toy play sessions later (group 1), or vice versa (group 2). In order to
differentiate the media used in these two conditions, the therapists in music
therapy were instructed to interact with the child mainly through music,
whereas the therapists in the toy play condition were instructed to engage the
child by any means, but to avoid any musical media, such as singing or rhythmic
playing.

Observed behaviors were
recorded in terms of both their frequency and their duration for two broad
categories. The first category concerned the participant’s emotional and
motivational responsiveness (joy, emotional synchronicity, initiation of
engagement) towards different types of attunement promoted by the therapist in
these two conditions. The second category concerned two different types of
responsiveness towards the therapist’s initiation of interaction (social
invitation and interpersonal demands). Joy referred to an event when the child
either smiled (facial expression duration only), or laughed (facial expression
with vocal sound) during the interaction with the therapist. Emotional
synchronicity referred to an event when the child and the therapist shared a
moment of emotional affect duration (happiness or sadness) while engaged with
each other. Initiation of engagement referred to an event where the child
spontaneously initiated interaction with the therapist, or initiated a change
during ongoing interaction, and then expected the therapist to follow.

Results and Discussion

Improvisational music
therapy produced markedly more and longer events of joy, emotional synchronicity
and initiation of engagement behaviors in the children than toy play sessions.
In response to the therapist’s interpersonal demands, ‘compliant (positive)
responses’ were observed more in music therapy than in toy play sessions, and
‘no responses’ were twice as frequent in toy play
sessions as in music therapy. In the music therapy condition, there were more joy,
emotional synchronicity and initiation of engagement events in the undirected
part than the directed part, suggesting that children were happier, more able
to express their happy emotions and more able to share their affects with the
therapist when leading. These results suggest that musical attunement enhances
musical-emotional communication together with joy and emotional synchronicity,
which results in children’s spontaneous willingness to respond, initiate and
engage further.

According to the authors,
“The temporal structure of music and the specific use of musical attunement in
improvisational music therapy suggests that we can help children with autism
experience and develop affective skills in a social context.” Creating music relates to the child’s
expression, interest and focus of attention may evoke responses from the child
to a therapist creating such relational music for them. Moreover, improvising
music together is an emotionally engaging process. Music can be an attractive
medium, allowing the child his/her own space and the choice of objects, at the
same time engaging the child with different objects of the therapist’s choice.

Of course, this
“exploratory” study has limitations.For
example, the small sample makes any generalizable conclusion premature. The
test power is low and should be considered when interpreting the results.
Likewise, the small sample limits the relevance of subgroup analyses (language,
age, severity) as well as therapists’ effects which would be helpful to
understanding how children with different developmental needs respond to this
type of intervention different therapists.

Conclusion

In conclusion, the results
of this exploratory study found significant evidence supporting the value of
music therapy in promoting social, emotional and motivational development in
children with autism. The findings highlight the importance of social-motivational
aspects of musical interaction between the child and the therapist, the
therapeutic potential of such aspects in improvisational music therapy, and the
relative value of less directed and more child centered approaches for children
with autism. The authors conclude, “Both previous and the current study
indicate that we should use music within the child’s focus of attention,
behavioral cue and interests, whether it is improvised or precomposed. A future
study should perhaps look at the differential effect on response of improvised
and precomposed music with young children with autism.”

Monday, August 10, 2015

The deletion of Asperger’s
disorder (Asperger's syndrome) as a separate diagnostic category from the fifth
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
has been widely publicized. The new DSM-5 category of autism spectrum
disorder (ASD), which subsumes the previous DSM-IV diagnoses of autistic
disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder
not otherwise specified (PDD-NOS), reflects the scientific consensus that
symptoms of the various DSM-IV subgroups represent a single continuum of
impairment that varies in level of severity and need for support.

An important feature of
the DSM-5 criteria for ASD is a change from three symptom domains (triad)
of social impairment, communication deficits and repetitive/restricted
behaviors, interests, or activities to two domains (dyad); social/communication
deficits and fixated and repetitive pattern of behaviors. Several
social/communication criteria were merged to clarify diagnostic requirements
and reflect research indicating that language deficits are neither universal in
ASD, nor should they be considered as a defining feature of the diagnosis. The
criteria also feature dimensions of severity that include current levels of language
and intellectual functioning as well as greater flexibility in the criteria for
age of onset and addition of symptoms not previously included in the DSM-IV such
as sensory interests and aversions.

DSM-IV Criteria in Practice

Problems in applying the DSM-IV
criteria were a key consideration in the decision to delete Asperger’s disorder
as a separate diagnostic entity. Numerous studies indicate that it is difficult
to reliably distinguish between Asperger syndrome, autism, and other disorders
on the spectrum in clinical practice (Attwood, 2006; Macintosh &
Dissanayake, 2006; Leekam, Libby, Wing, Gould & Gillberg, 2000; Mayes &
Calhoun, 2003; Mayes, Calhoun, & Crites, 2001; Miller & Ozonoff, 2000;
Ozonoff, Dawson, & McPartland, 2002; Witwer & Lecavalier, 2008). For
example, children with autism who develop proficient language have very similar
trajectories and later outcomes as children with Asperger disorder (Bennett et
al., 2008; Howlin, 2003; Szatmari et al., 2000) and the two are
indistinguishable by school-age (Macintosh & Dissanayake, 2004),
adolescence (Eisenmajer, Prior, Leekam, Wing, Ong, Gould & Welham 1998;
Ozonoff, South and Miller 2000) and adulthood (Howlin, 2003). Individuals with
Asperger disorder also typically meet the DSM-IV communication criterion of
autism, “marked impairment in the ability to initiate or sustain a conversation
with others,” making it is possible for someone who meets the criteria for
Asperger’s disorder to also meet the criteria for autistic disorder.

Treatment and Outcome

Another important consideration
was response to treatment. Intervention research cannot predict, at the present
time, which particular intervention approach works best with which individual.
Likewise, data is not available on the differential responsiveness of children
with Asperger’s disorder and high-functioning autism to specific interventions
(Carpenter, Soorya, & Halpern, 2009). There are no empirical studies
demonstrating the need for different treatments or different responses to the
same treatment, and in clinical practice the same interventions are typically
offered for both autism and Asperger’s disorder (Wilkinson,
2010). Treatments for impairments in pragmatic (social) language and
social skills are the same for both groups.

Application of DSM-5 Criteria

It’s important to remember
that in the DSM, a mental disorder is conceptualized as a clinically important
collection of behavioral and psychological symptoms that causes an individual
distress, disability or impairment. The objective of the DSM-5 criteria for ASD
is that every individual who has significant “impairment” in
social interaction and communication, and restricted and repetitive behavior or interests should
meet the diagnostic criteria for ASD. Because language impairment/delay is not a necessary
criterion for diagnosis, anyone who demonstrates severe and sustained
impairments in social skills and restricted, repetitive patterns of behavior,
interests, or activities in the presence of generally age-appropriate language
acquisition and cognitive functioning, who might previously have been given a
diagnosis of Asperger’s disorder, now meet the criteria for ASD. Specifiers are used to indicate level of severity and "without accompanying intellectual impairment and language impairment."

The DSM-5 criteria for
ASD have created significant controversy over concerns that it would exclude
many individuals currently diagnosed with Asperger syndrome and PDD-NOS, and
thus make it difficult for them to access services. However, recently published
field trials suggest that the revisions actually increase the reliability of
diagnosis, while identifying the large majority of those who would have been
diagnosed under the DSM-IV-TR. Of the small numbers who were not included, most
received the new diagnosis of “social communication disorder.” Moreover, the
accuracy of non-spectrum classification (specificity) made by DSM-5 was better
than that of DSM-IV, indicating greater effectiveness in distinguishing ASD
from non-spectrum disorders such as language disorders, intellectual
disability, attention-deficit/hyperactivity disorder (ADHD), and anxiety
disorders. It is also important to note that all individuals who have a DSM-IV
diagnosis on the autism spectrum, including those with Asperger syndrome and
PDD-NOS, will be able to retain an ASD diagnosis. This means that no one should
“lose” their diagnosis because of the changes in diagnostic criteria. According to DSM-5, individuals with a
well-established DSM-IV diagnosis of Autistic Disorder, Asperger’s Disorder, or
PDD-NOS should be given a diagnosis of ASD.
Those who have marked deficits in social communication, but whose
symptoms do not meet the criteria for ASD, should be evaluated for Social
(Pragmatic) Communication Disorder.

Conclusion

In conclusion, the DSM-5
category of autism spectrum disorder (ASD), which subsumes the current
diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive
developmental disorder not otherwise specified (PDD-NOS), better describes our
current understanding about the clinical presentation and course of the
neurodevelopmental disorders. Conceptualizing autism as a spectrum condition
rather than a categorical diagnostic entity is in keeping with the extant
research suggesting that there is no clear evidence that Asperger’s disorder
and high-functioning autism are different disorders. As Gillberg (2001) notes,
the terms Asperger's syndrome and high-functioning autism are more likely
“synonyms” than labels for different disorders. Lord (2011) also comments that
although there has been much controversy about whether there should be separate
diagnoses, "Most of the research has suggested that Asperger's syndrome
really isn't different from other autism spectrum disorders." "The
take-home message is that there really should be just a general category of
autism spectrum disorder, and then clinicians should be able to describe a
child's severity on these separate dimensions." Unfortunately, many
individuals may have been advised (or assumed) that a diagnosis of Asperger’s
disorder was separate and distinct from autism and that
intervention/treatment, course, and outcome were clinically different for each
disorder. While including Asperger’s Disorder under the DSM-5 category of ASD
will likely continue to require a period of transition and adjustment, the
proposed dimensional approach to diagnosis will likely result in more effective
identification, treatment, and research for individuals on the spectrum.

different Disorders? Journal
of Developmental and Learning Disorders, 5, 79-94.

Howlin, P. (2003). Outcome
in high-functioning adults with autism with and without early language delays:
Implications for the differentiation between autism and Asperger syndrome. Journal
of Autism and Developmental Disorders, 33, 3–13.

Monday, August 3, 2015

The dramatic increase in the rate of autism among children enrolled in special education programs in the United States may be due in large part to the reclassification of students who previously would have been given other disability labels. In a paper published online in the American Journal of Medical Genetics, scientists at Penn State reported their analysis of 11 years of data from the United States Individuals with Disabilities Education Act (IDEA) for students enrolled in special education programs. Under IDEA, individuals are classified into one of 13 disability categories including autism, intellectual disability, emotional disturbance, other health impairment and specific learning disability.

The researchers found that between 2000 and 2010, the number of children in the autism category more than tripled from 93,624 in 2000 to 419,647 a decade later. Yet nearly 65 percent of this increase was significantly associated with a corresponding decline in the number of students classified under the intellectual disability category in the IDEA data. The researchers estimate that, for 8 year-olds, approximately 59 percent of the observed increase in autism is accounted for by reclassification, but by age 15, reclassification accounts for as much as 97 percent of the increase in autism. Likewise, the researchers found the category of specific learning disability as another potential contributor to diagnostic reclassification. They also note that the relationship between autism cases and disability categories varied state-by-state, suggesting that state-specific health policy may be a significant factor in estimates of autism prevalence.

Although a broadening of diagnostic criteria, improved assessment practices, increased awareness of autism, and strategic use of diagnosis to gain access to services have all had a significant effect on the prevalence of autism, this research provides the first direct evidence that much of the increase may be attributable to a reclassification of children with related disorders (or diagnostic substitution) rather than to an actual increase in the rate of new cases of autism. The researchers conclude that the large increase in the prevalence of autism is likely the result of students being moved from one category to another and is complicated by the variability of autism and its overlap with other related disorders. Current prevalence estimates are based on specific clinical features of autism and do not consider co-occurring disorders that may confound diagnosis and classification. "Because features of neurodevelopmental disorders co-occur at such a high rate and there is so much individual variation in autism, diagnosis is greatly complicated, which affects the perceived prevalence of autism and related disorders," said Santhosh Girirajan, assistant professor of biochemistry and molecular biology and of anthropology at PennState and the leader of the research team. "For quite some time, researchers have been struggling to sort disorders into categories based on observable clinical features, but it gets complicated with autism because every individual can show a different combination of features. The tricky part is how to deal with individuals who have multiple diagnoses, because the set of features that define autism is commonly found in individuals with other cognitive or neurological deficits."

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